Cover L​e​​tter

Letter on company letterhead with the following information:

• License number
• Facility name and ID number (if known)
• Brief description of request
  
• Contact information (name, title, phone number, and e- mail address)
• Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information (CAHAN) (https://www.calhospitalprepare.org/cahan)
  
• Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) 
• ​​​Signature​
  

Submit the CDPH 322 form for the Administrator to the address indicated on the form. ​

Applicant Individual Information

(REVISED 7/2023)

(Title 22 California Code of Regulations (CCR) section 74661 (a)(5) & 74665) (HSC section 1728)

This form must be completed for administrators and include signature.

Tips:

• Page 2, section B, item 3 — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification. 
• Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity  
• Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week. 
• Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section D; however, the resume must contain all required information requested in section D

• Page 7, section F — If answering yes to any question in this section, complete Section H, Facility Information Sheet
  

Resume

A resume is only required for the Administrator​​​(s).